Medical Auditing Practice Exam

What materials are typically needed when performing a retrospective audit?

1. Audit form, coding manuals, and office supplies.

2. Medical record, audit form, coding manuals, and payer policies.

3. Billing statements, healthcare guidelines, and physician feedback.

4. Patient surveys, medical records, and financial reports.

The correct answer is: Medical record, audit form, coding manuals, and payer policies.

When performing a retrospective audit, having access to comprehensive and relevant materials is crucial for a thorough review. The inclusion of medical records allows auditors to examine the patient's clinical history, treatments provided, and any associated documentation that supports claims submitted to payers. This is essential for verifying that the services billed were indeed provided and medically necessary. The audit form is a critical tool for systematically capturing findings during the review process, ensuring that all necessary data points are evaluated consistently. Meanwhile, coding manuals provide guidance on the accurate application of coding systems (like ICD, CPT, and HCPCS), which are integral for assigning the correct codes to diagnoses and procedures based on the medical records. Lastly, payer policies offer insights into reimbursement criteria and guidelines that must be adhered to when submitting claims. Understanding these policies helps in determining if the claims align with payer requirements, which is essential in identifying potential billing errors or areas of non-compliance. In summary, the combination of medical records, an audit form, coding manuals, and payer policies ensures that the retrospective audit is comprehensive, accurate, and aligned with regulatory standards and payer expectations.